Procedure Based Coding

Procedure Based Coding Jon K. Hathaway Objectives Review Global definition Review common modifiers Procedure plus E&M codes 2013 MSACOG Snow Meeting 1

Vacuum assisted Vaginal Delivery was first reported in the literature in what year? 1. 1632 2. 1706 3. 1794 4. 1836 0% 0% 0% 0% 1632 1706 1794 1836 CPT 4 Identifies procedures performed. Assigns a work value to each procedure also known as an RVU or relative value unit. 2013 MSACOG Snow Meeting 2

CPT-4 Let s jump in Global Package 2013 MSACOG Snow Meeting 3

Definition Global Package Includes Pre-Op H&P done the day before or day of surgery. Does not include the pre-op visit one week before to finalize counseling and confirm plan. Includes certain pre-operative tasks. Includes certain operative tasks. Includes certain post-operative tasks. Hospital Office Sometimes includes other procedures. Global Packages Minor Pre-Op: Same day visits Intra-Op: Procedure, supplies, anesthesia Post-Op: 0 day global procedures 10 day global procedures Does not include any visits, related or not, outside the global period. Major Pre-Op: All visits beginning one day before the surgery, including the hospital admission work-up. Intra-Op: Procedure and any surgeon administered anesthesia. Post-Op: Post-op visits related to the procedure up to 90 days after the service Does not include the E/M service in which the decision was made to perform the surgery, diagnostic tests/procedures, stabilization prior to surgery, unrelated post-op visits, treatment for post-op complications requiring a return trip to the OR (e.g., wound dehiscence or infection requiring OR debridement). 2013 MSACOG Snow Meeting 4

57454 Colposcopy of the Cervix (including adjacent/upper vagina), with biopsy of cervix AND ECC. Pre-Op: Positioning, prepping and draping and catheter placement. Intra-Op: Speculum, enhancing medium, exam, biopsy, ECC, hemostasis, local. Post-Op: Dressing/Packing, evaluation/stabilization, dictation, review of pathology, completion of patient record, instructions to patient, consultation with family. Additional included procedures: Suturing or cautery of biopsy site 57454 Does not include: Destruction of vulvar lesions Vulvar colposcopy Destruction of vaginal lesions EMB 2013 MSACOG Snow Meeting 5

57454 RVU: Hospital 3.71 Office 4.19 Global period: 0 days Assistant: Not covered. Co-surgeon: Not covered. What if. You didn t do biopsy and/or ECC? Separate codes for colpo only, colpo with ECC (no biopsy), colpo with biopsy (no ECC). 2013 MSACOG Snow Meeting 6

A patient is seen in the office for colposcopy due to an abnormal pap done at her family doctor s office. Correct billing is: 1. Colposcopy with or without biopsy/ecc 2. Office visit and colposcopy on the following day. 3. Office visit and colposcopy with or without biopsy/ecc 4. Consultation and colposcopy with or without biopsy/ecc Colposcopy wit... 0% 0% 0% 0% Office visit a... Office visit a... Consultation a... Three modifiers to remember 22: Unusual and increased services. 25: Procedure and E&M on the same day. 57: Decision to perform surgery. 2013 MSACOG Snow Meeting 7

Visit + Procedure F.S. is a 23 yo G0 who presents to the ER c/o RLQ tenderness. ER physician performs and exam and determines she needs a CT scan to evaluate the appendix. CT shows no appy but +fluid in abdomen c/w blood, recommend clinical correlation. In the meantime, F.S. s pregnancy test comes back positive. You are paged and perform/document a Hx and PE deemed worthy of a Est. Pt. level 4 visit. During this exam, it is determined that the patient requires a trip to the OR for dx laparoscopy, possible ectopic. 2013 MSACOG Snow Meeting 8

Dx L/S shows R ectopic pregnancy which was removed laparoscopically by salpingectomy and the patient was discharged home after an uneventful PACU stay and stable VS. What should you bill? 1. Dx L/S, L/S salpingectomy 2. Dx L/S, L/S salpingectomy + outpatient office visit 3. L/S treatment of ectopic 4. L/S treatment of ectopic + outpatient office visit 5. L/S treatment of ectopic + inpatient office visit. 0% 0% 0% 0% 0% 1 2 3 4 5 2013 MSACOG Snow Meeting 9

What should you bill/code? Should you get paid for your services in the ER? 99214 What procedures were performed? Dx Laparoscopy (49320-8.33 RVU) L/S salpingectomy (58661-17.48 RVU) Exam under anesthesia However 59151: L/S tx of ectopic with salpingectomy/oophorectomy Includes Dx L/S 20.51 RVUs Why does this one pay so much less? 2013 MSACOG Snow Meeting 10

Final Bill 99214-57 (Level 4 visit that resulted in the decision to perform major surgery.) 59151 L/S tx of ectopic with excision. Use modifier -25 (E&M plus a minor procedure) in the ER or office when you make a decision to perform a EMBx, word catheter placement or I&D. Can also use this code in the office when you make a decision to perform an IUD placement. All of the following were treatments for menorrhagia except? 1. Ligatures applied to the armpits and groin. 2. Intravaginal liquid pitch 3. Eating bread made from black rye. 4. Intravaginal burnt cork 5. Cupping applied to the breast Ligatures appl... 0% 0% 0% 0% 0% Intravaginal l... Eating bread m... Intravaginal b... Cupping applie... 2013 MSACOG Snow Meeting 11

Mrs. Smith 53 y.o. postmenopausal woman who presents c/o postmenopausal bleeding. Was sent to you by her PCP. What next? Mrs. Smith Consultation with appropriate documentation of a new patient/consultation level 3. Decide to perform an EMB. EMB attempted, but os was too stenotic to allow pipelle to pass. 2013 MSACOG Snow Meeting 12

What should you bill? 1.Level 3 E&M 2.Endometrial bx 3.-25 modifier 4.-53 modifier (abandoned procedure). 0% 0% 0% 0% 1 2 3 4 Billing Mrs. Smith 99243: Level 3 consultation. 58100: EMB Add a -25 modifier to the consult. Provided an E & M visit that resulted in the need to perform a minor procedure. Some providers will schedule on separate days. Add a -53 modifier to the procedure. Abandoned procedure. Send letter to referring physician!!! 2013 MSACOG Snow Meeting 13

Mrs. Johnson 27 yo G1P0 seen in the office for prenatal care. Found to have elevated BP so was sent to triage for evaluation. Was seen in triage, labs done (normal) and sent home with a 24 hour urine protein. Mrs. Johnson s Bill Two visits vs. One visit One visit Bill the E & M code that fits the service provided (including any tests/ultrasounds). Not included in routine OB care. 2013 MSACOG Snow Meeting 14

Mrs. Johnson (part 2) Mrs. Johnson seen for routine OB care. Later that day, Mrs. Johnson is in a car accident and admitted for 4 hour observation. Bill for routine OB visit AND bill for the E & M code because there is a separate ICD-9 diagnosis (use modifier 59). Mrs. Lopez C/S was performed at 8 AM. Pt had a PPH at 2 PM. Despite your best efforts, a hysterectomy was required and performed at 5 PM. 2013 MSACOG Snow Meeting 15

Mrs. Lopez s bill Bill for the C/S Bill for the hysterectomy (which includes an exploratory laparotomy) with modifier -78 (return to OR for complication within the global period). If planned C/S+hyst then use the hysterectomy at time of C/S add on code. A patient presents to the ER for evaluation and sent home. The correct code set to use is: 1. Outpatient 2. Inpatient Admit 3. Inpatient Observation 4. Emergency Room 0% 0% 0% 0% Outpatient Inpatient Admi... Inpatient Obse... Emergency Room 2013 MSACOG Snow Meeting 16

Gyn is called in to evaluate an ovarian cyst on exlap. An oophorectomy is performed. They should bill: 1. Assistant surgeon on the exploratory laparotomy. 2. Consultation code and surgeon for any procedure performed. 3. Consultation code based on time only no procedure. 4. Primary surgeon on oophorectomy cannot bill consultation because she is asleep and cannot get ROS. Assistant surg... 0% 0% 0% 0% Consultation c... Consultation c... Primary surgeo... Gyn Oncology is called in to assist on a hysterectomy. They should bill: 1. Assistant surgeon on the hysterectomy. 2. Consultation code and surgeon for any procedure performed. 3. Consultation code based on time only no procedure. 4. Primary surgeon on hysterectomy. Assistant surg... 0% 0% 0% 0% Consultation c... Consultation c... Primary surgeo... 2013 MSACOG Snow Meeting 17

HELP Sources: Essential guide to Coding in OB/GYN OB/GYN Coding Manual FAQ for OB/GYN CPT-4 and ICD-9 books/online Coding courses Any Questions??? 2013 MSACOG Snow Meeting 18

The End Inpatient Coding Admission care: Subsequent care: Discharge care: Admission/Discharge same day care: Observation care: Consultation care: 2013 MSACOG Snow Meeting 19

Admission Care History Exam Decision Time RVU (Work/Total) 99221 Detailed or Comprehensive Detailed or Comprehensive Straightforward or Low 30 min. 1.92/2.64 99222 Comprehensive Comprehensive Moderate 50 min. 2.61/3.58 99223 Comprehensive Comprehensive High 70 min. 3.86/5.26 99221: 21 yo at 9 weeks admitted for hyperemesis gravidarum. 99222: 23 yo admitted with PID. (ACOG book) 99223: 16 yo at 32 weeks with severe HTN, thrombocytopenia and headache. Subsequent Hospital Care (Need 2 of 3 or time) History Exam Decision Time RVU (Work/Tot al) 99231 Problemfocused Problemfocused Straightforward/ Low 15 min. 99232 Expanded PF Expanded PF Moderate 25 min. 99233 Detailed Detailed High 35 min. 99231: 33 yo admitted for pelvic pain who is responding to medication and observation. 21 yo admitted for hyperemesis who is responding well to fluids. 0.76/1.06 1.39/1.91 2.00/2.74 2013 MSACOG Snow Meeting 20

Discharge Care (From inpatient) RVU (Work/Total) 99238 30 minutes or less 1.28/1.88 99239 More than 30 minutes 1.90/2.74 Includes: Exam, discussion of hospital stay and postdischarge care guidelines, instructions for continuing care to all relevant caregivers, preparation of discharge records, prescriptions and referral forms. Admission & Discharge Same Day History Exam Decision RVU (Work/To tal) 99234 Detailed/ Comprehensive Detailed/ Comprehensive Straightforward/ Low 2.56/3.59 99235 Comprehensive Comprehensive Moderate 3.41/4.71 99236 Comprehensive Comprehensive High 4.26/5.84 Medicare requires inpatient/observation care for at least 8 hours. If less than 8 hours, just use admission codes (no discharge). 2013 MSACOG Snow Meeting 21

Observation Care History Exam Decision RVU (Work/Total) 99218 Detailed/ Comprehensive Detailed/ Comprehensive Straightforward/ Low 1.28/1.77 99219 Comprehensive Comprehensive Moderate 2.14/2.93 99220 Comprehensive Comprehensive High 2.99/4.10 99217 Discharge care on separate date. 1.28/1.88 These are used for patients who are being observed to see if they warrant admission, transfer or discharge. Inpatient Consultation History Exam Decision Time RVU (work/total) 99251 Problem-focused Problem-focused Straightforward 20 min 1.00/1.37 99252 Expanded PF Expanded PF Straightforward 40 min 1.50/2.11 99253 Detailed Detailed Low 55 min 2.27/3.22 99254 Comprehensive Comprehensive Moderate 80 min 3.29/4.65 99255 Comprehensive Comprehensive High 110 min 4.00/5.62 Medicare does NOT pay for any consultation, inpatient or outpatient. 2013 MSACOG Snow Meeting 22

A patient is admitted before midnight. She is seen by the attending the next day and discharged home. What code should the attending use? 1. Initial observation care on day of admission and discharge care on the day of discharge. 2. Admission and discharge on same day. 3. Only discharge services on day of discharge. 4. Initial observation care on day of discharge. Initial observ... 0% 0% 0% 0% Admission and... Only discharge... Initial observ... Examples of A&D codes Physician A admits her patient to observation at 10AM for gastroenteritis and dehydration at 22 weeks gestation. At 5:30PM she is re-evaluated by the on-call physician and discharged home. Medicare: Observation codes only. CPT: A&D codes. 2013 MSACOG Snow Meeting 23

On the way home from the hospital, the patient is in a serious car accident and returns to the hospital with contractions. She is admitted for 24 hour observation. To bill correctly, you should: 1. Change the prior discharge and just bill for continuing care. 2. Bill for the admission, but not the discharge. 3. Bill for the discharge but not the admission. 4. Bill for both an admission and a discharge. Change the pri... 0% 0% 0% 0% Bill for the a... Bill for the d... Bill for both... The next morning she is discharged home. You should bill: 1. Discharge from observation code. 2. Discharge from inpatient care. 3. Bill an A&D code because the admit and discharge were less than 24 hours apart. 4. No charge, you just reviewed the NST anyway. Discharge from... 0% 0% 0% 0% Discharge from... Bill an A&D co... No charge, you... 2013 MSACOG Snow Meeting 24